WJOLS 10.5005/jp-journals-10007-1146 REVIEW ARTICLE Role of Robotics in Whipple’s Role of Robotics in Whipple’s Surgery

B Srinivas

ABSTRACT In computer-controlled systems, the surgeon uses a Whipple is one of the most demanding and complex computer to control the robotic arms and its end-effectors, of the abdomen. It is the most commonly performed operation though these systems can also still use telemanipulators for for pancreatic cancer, the fourth leading cause of cancer death their input. One advantage of using the computerized in the United States. For patients with benign as well as malignant pancreatic tumors, it is believed that the robotic method is that the surgeon does not have to be present, Whipple procedure will be a major improvement over the indeed the surgeon could be anywhere in the world, leading traditional procedure. The robotic surgery involves five small to the possibility for remote surgery. incisions (one to accommodate a miniature camera), rather than a large incision and separation, not cutting of muscles. HISTORY Keywords: Robotic Whipple’s surgery, Robotic surgery, Da Vinci Whipple’s surgery. 1985: A robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.3,4 How to cite this article: Srinivas B. Role of Robotics in Whipple’s Surgery. World J Lap Surg 2012;5(1):39-45. 1988: The PROBOT, developed at Imperial College London, was used to perform prostatic surgery. Source of support: Nil 1992: The ROBODOC from Integrated Surgical Systems Conflict of interest: None declared was introduced into mill out precise fittings in the femur for hip replacement.9 INTRODUCTION 1997: A reconnection of the fallopian tubes operation A robotic device is a powered, computer-controlled was performed successfully in Cleveland using manipulator with artificial sensing that can be reprogrammed ZEUS. to move and position tools to carry out a wide range of May 1998: Dr Friedrich Wilhelm Mohr using the da tasks.1 Telemanipulators and robots were first developed Vinci surgical system performed the first robotically by the National Aeronautics and Space Administration assisted heart bypass. (NASA) for use in space exploration. In 1985, NASA September 2010: The Eindhoven University of instituted a research program in telerobotics to develop the Technology announced the development of Sofie technology for the United States Space Program.2 surgical system, the first surgical robot to employ force The medical robotic systems of present generation are feedback. the brainchild of the United States Department of Defence’s The intuitive surgical introduced the da Vinci desire to decrease war casualties with the development of surgical system and computer motion with the AESOP ‘telerobotic surgery’. The ‘master-slave’ telemanipulator and the ZEUS robotic surgical system. (Intuitive surgical concept was developed for medical use in the early 1990s bought computer motion in 2003; ZEUS is no longer where the surgeon’s (master) manual movements were being actively marketed).5-7 transmitted to end-effector (slave) instruments at a remote Three main types of surgical robots available at present site. The field of surgical robotics has undergone massive are as follows: transformation since then and the future is even brighter.2 1. Supervisory-controlled Robotic Surgery Systems (e. g. Robotically-assisted surgery was developed to overcome the ROBODOC® system from CUREXO Technology the limitations of minimally invasive surgery. Corporation): It is the most automated surgical robots Methods of controlling the instruments in robotic available till date. Surgeons can plan their surgery surgery: preoperatively in a 3D virtual space and then execute 1. Telemanipulator the surgery exactly as planned in the operating theater. 2. Computer-controlled system 2. Shared-control Robotic Surgery Systems: These robots A telemanipulator is a remote manipulator that allows aid surgeons during surgery, but the human does most the surgeon to perform the normal movements associated of the work. with the surgery, while the robotic arms carry out those 3. Telesurgical devices: Here, the surgeon directs the movements using end-effectors and manipulators to perform motions of the robot, e.g. the da Vinci robotic system, the actual surgery on the patient. the ZEUS surgical system. World Journal of Laparoscopic Surgery, January-April 2012;5(1):39-45 39 B Srinivas

The da Vinci surgical system comprises three AIM OF STUDY components: The aim of this review article is to appraise and to evaluate A surgeon’s console, the present and future role of robotics in Whipple’s surgery. A patient-side robotic cart with four arms manipulated The following parameters were evaluated: by the surgeon (one to control the camera and three to 1. Patient and disease factors manipulate instruments), and 2. Technical considerations A high-definition 3D vision system. Articulating surgical 3. Operating time instruments are mounted on the robotic arms which are 4. Intra- and postoperative complications introduced into the body through cannulas. 5. Postoperative morbidity Three generations of da Vinci surgical systems have 6. Hospital stay developed so far:8 7. Cost-effectiveness 1. da Vinci surgical system (1999): It consists of three 8. Quality of life analysis. components: The viewing and control console, surgical arm unit (three or four arms depending on the model) MATERIALS AND METHODS and optical three-dimensional vision tower (Figs 1A to C). A literature search was performed using search engine 2. da Vinci S HD surgical system (2006): This second google, Springer, HighWire, Sages, IJA, PubMed, etc. and generation surgical robot is equipped with wide range the literature analyzed. of motion of robotic arms and extended length instruments, interactive video displays and touch screen KEYWORDS monitor. 3. da Vinci Si HD surgical system (2009): It has da Vinci robotic system dual console capability to support training and Robotic Whipple collaboration, advanced 3D HD visualization with up Robotic pancreaticoduodenectomy to 10× magnification, ‘EndoWrist’® instrumentation Robotic surgery with dexterity and range of motion more than the human Minimally invasive surgery hand and ‘Intuitive® motion technology’(Figs 2A and B), Pancreatectomy which replicates the experience of open surgery by Pancreatic resection preserving natural eye-hand-instrument alignment.8 The Pancreaticoduodenectomy new da Vinci HD SI released in April, 2009 currently Whipple’s surgery. sells for $1.75 million. CARCINOMA OF THE PANCREAS AND SYNONYMS PERIAMPULLARY AREA Robotic surgery Essentials of diagnosis: Computer-assisted surgery Obstructive jaundice (may be painless) Robotically-assisted surgery. Enlarged gallbladder (Courvoisier’s sign)

A B C Figs 1A to C: (A) The da Vinci system surgeon console (B) The cart with three mounted surgical arms (C) joysticks with viewing ports in the console (courtesy: Intuitive Surgical Inc, Sunnyvale, CA) 40 JAYPEE WJOLS

Role of Robotics in Whipple’s Surgery

Upper abdominal pain with radiation to back, weight IMAGING loss and thrombophlebitis are usually late mani- CT scan: A multiphase helical CT scan is the initial festations. diagnostic tool and detects a mass in more than 80% of Risk factors for pancreatic cancer: cases. Age Endoscopic ultrasound Obesity PET scan Tobacco use MRI Family history ERCP Heavy alcohol use MRCP. Chronic pancreatitis Prior abdominal radiation WHIPPLE’S SURGERY Previous H/O partial gastrectomy. Whipple’s surgery is done for: Cancer of the head of the pancreas GENERAL CONSIDERATIONS Cancer of the duodenum Ductal adenocarcinoma is the most common neoplasm of Cholangiocarcinoma (cancer of the pancreatic end of the pancreas. Other neoplasms of pancreas include: the bile) Mucinous cyst adenocarcinoma Cancer of the ampulla Serous cyst adenoma Whipple operation may also sometimes be performed Mucinous cyst adenoma for patients with benign (noncancerous) disorders such Malignant exocrine tumors as chronic pancreatitis and benign tumors of the head Benign exocrine tumors of the pancreas. Endocrine – Gastrinoma Advantages of Robotic Whipple – Insulinoma. The robotic Whipple offers patients a minimally invasive Carcinomas involving the head of the pancreas, the option to the traditional surgeries for pancreatic cancer and ampulla of Vater, the distal common bile duct and the benign tumors of the pancreas and colon, resulting in the duodenum are considered together, because they are usually potential for: indistinguishable clinically; of these, carcinomas of the Less pain pancreas constitute over 90%. About 75% are in the head Shorter hospital stays and 25% in the body and tail of the organ. They comprise Faster recovery times 2% of all cancers and 5% of cancer deaths. Risk factors Minimized scarring include new-onset diabetes mellitus after the age of 45 years, Blood loss occasionally heralds the onset of early pancreatic cancer. Less complications.

A B Figs 2A and B: (A) New generation robotic instruments have seven degrees of freedom as the human hand, (B) EndoWrist’® instrument from intuitive surgical (Courtesy: Intuitive Surgical Inc, Sunnyvale, CA) World Journal of Laparoscopic Surgery, January-April 2012;5(1):39-45 41 B Srinivas

LIMITATIONS OF ROBOTIC-ASSISTED SURGERY The presence of a replaced right hepatic artery and the position of the 1st jejunal vein (J1) branch, as it Patient safety in the event of robot malfunction and crash enters the right side of the superior mesenteric vein, down is a concern and the operating room staff should be should be assessed in order to avoid any inadvertent aware of it. Robotic technology is a complex issue and needs injury a lot of practice and technical expertise. Robotic surgery Short stature and obesity create excess intra- needs longer operating room time compared with abdominal fat which makes robotic dissection conventional surgeries. Several pieces of equipment, each difficult. being extremely bulky, require large operating room space.11 2. , port setting and robot docking: A The staff must be trained and prepared to quickly detach laparoscopic investigation of the abdominal cavity is and remove the robot from the patient in the event of an essential prior to any major pancreas tumor resection emergency. Current robotic systems lack tactile feedback (NCCN guidelines). The laparoscopy not only allows from the instruments.12 surgical staging, but also allows identification of acute Surgeons have to rely on visual clues to modulate the or chronic pancreatitis, an unfavorable body habitus or amount of tension and pressure applied to tissues to avoid other unforeseen obstacles to a robotic procedure.10 organ damage. The newly launched da Vinci HD SI system Robotic trocar placement: The camera port is positioned costs $1.75 million. Initial increased operating room setup slightly to the patient’s right side and inferior to the time and surgical time adds to the cost burden. However, umbilicus. The camera port is approximately 18 cm from robot- assisted surgery has shown to reduce hospital stay the operative focus, and the robotic axis is slightly to by about half and thereby cutting hospital cost by about the patient’s right side of midline. The right robotic arm 33%.13 is placed in the upper left-hand corner of the abdomen. One major obstacle to the telerobotic surgery is the The robotic left hand is in the patient’s left lower ‘latent time’, which is the time taken to send an electrical quadrant, with the robotic 3rd arm below the patient’s signal from a hand motion to actual visualization of the right costal margin (after pneumoperitonealization). hand motion on a remote screen. Humans can compensate Assistant operating ports are positioned in the right and for delays of less than 200 msec14 (Table 1). Longer delays left abdominal quadrants. The robotic ports should be compromise surgical accuracy and safety. Incompatibility 8 to 10 cm apart, if possible, while the assistant ports with imaging equipment is an area that needs attention. should be at least 5 cm from additional port sites.10 3. Mobilization of duodenum (kocherization) and exposure THE STEPS IN A ROBOTIC WHIPPLE of the superior mesenteric/portal vein PROCEDURE10 (FIGS 3 TO 5) 4. Exploration of the porta hepatis 1. Preoperative considerations: Patient and disease 5. Mobilization of the ligament of Treitz factors: 6. Transecting the pancreas and dissecting the uncinate Preoperative evaluation of acute or chronic process pancreatitis which if present makes robotic dissection 7. Reconstruction: Pancreaticojejunostomy, hepatico- difficult jejunostomy and gastrojejunostomy.

Table 1: Advantages and disadvantages of conventional laparoscopic surgery vs robot-assisted surgery Conventional laparoscopic surgery Robot-assisted surgery Advantages Well-developed technology 3D visualization Affordable and ubiquitous Improved dexterity Proven efficacy Seven degrees of freedom Elimination of fulcrum effect Elimination of physiologic tremors Ability to scale motions Microanastomoses possible Telesurgery Ergonomic position Disadvantages Loss of touch sensation Absence of touch sensation Loss of 3D visualization Very expensive Compromised dexterity High start-up cost Limited degrees of motion May require extra staff to operate The fulcrum effect New technology Amplification of physiologic tremors Unproven benefit

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A B Figs 3A and B: Creation of the retropancreatic tunnel, along the anterior border of the superior mesenteric vein and portal vein confluence. Dissection is completed under direct visualization, which is facilitated by the position of the robotic camera. Completing the tunnel under direct visualization improves the safety of the Whipple procedure10

A B Figs 4A and B: (A) Elevation of the pancreatic head and uncinate process in an anterior fashion out of the retroperitoneum. The superior mesenteric vein and portal vein confluence is visualized in the center of the photograph. The elevation of the pancreatic tissue allows excellent visualization of the uncinate process and its retroperitoneal attachments. (B) As the uncinate process is mobilized from the retroperitoneum, the Wrst jejunal vein branch must be anticipated. The photograph illustrates the 1st jejunal vein, with the vein branch entering the inferior portion of pancreatic head10

LITERATURE REVIEW Whipple procedure remains a standard surgical procedure for periampullary carcinoma.16 Since the first laparoscopic cholecystectomy in 1989, minimally invasive surgery has become the alternative approach to conventional open surgery in many abdominal procedures.17 In early laparoscopic years, most surgeons used only diagnostic laparoscopy to evaluate periampullary malignancies or staging pancreatic cancer.18 With the benefit of minimal invasive surgery and new advances in technology and instrumentation, some surgeons began to apply it to more sophisticated procedures such as Whipple procedure.19 Fig. 5: Suturing of the pancreatic duct during the pancreaticojejunos- Gagner and Pomp reported the first laparoscopic tomy creation. The duct-to-mucosa anastomosis is created with a Whipple procedure in 1994.20 However, because of the 4-0 Vicryl suture on an RB1 needle. The pancreas parenchyma and pancreatic duct are seen on the right side of the photograph, technical difficulty, not many laparoscopic Whipple while the jejunum is visualized on the left10 procedures were performed. Several prospective randomized World Journal of Laparoscopic Surgery, January-April 2012;5(1):39-45 43 B Srinivas

Table 2: Advantages and disadvantages of robot-assisted surgery vs conventional surgery Human strengths Human limitations Robot strengths Robot limitations Strong hand-eye Limited dexterity outside Good geometric accuracy No judgment coordination natural scale Dexterous Prone to tremor and fatigue Stable and untiring Unable to use qualitative Flexible and adaptable Limited geometric accuracy information Can integrate extensive and Limited ability to use Scale motion Absence of haptic sensation diverse information quantitative information Can use diverse sensors Expensive Rudimentary haptic abilities Limited sterility in control Able to use qualitative Susceptible to radiation May be sterilized Technology in flux information and infection Resistant to radiation and More studies needed Good judgment infection Easy to instruct and debrief trials showed no difference in leakage and fistula rate Whether the current-generation surgical robot is between pancreaticogastrostomy and pancreaticojejunos- advanced enough to allow routine performance of pancreatic tomy.21-23 The duct to mucosa technique was utilized for head tumor resections remains to be seen. In an operation both pancreaticogastrostomy and hepaticojejunostomy. like the Whipple procedure, where we rely so heavily on Such a technique showed low or at least the same rate of blind palpation for careful dissection of the portal vein off leakage compared to the conventional method.24,25 the posterior pancreatic surface, it is possible that the da Two major concerns that anticipate early adoption of Vinci’s lack of haptic feedback may preclude its safe laparoscopic Whipple comprised of the difficult surgical application.28-30 technique, resulting in a long operative time, as well the CONCLUSION oncologic question about the adequacy of the laparoscopic operation.19,26 To shorten the learning curve of laparoscopic Robotic-assisted minimally invasive pancreaticoduodenec- approach, the hand-assisted hybrid technique had been used tomy can be performed safely and effectively with with favorable results Table 2. Recently, robotic Whipple significant individual and institutional preparation and using the da Vinci system has also been shown to be feasible commitment. Safety is directly related to the surgical team’s and efficient.27 ability to complete the operative procedure in an open All the benefits of minimally invasive surgery may be fashion, and a breadth of experience dealing with complex expected from the robotic Whipple procedure. Patients interoperative hepatobiliary complications. If oncological undergoing robotic procedure mobilize earlier than their principles and/or safety are compromised, the procedure 10 open counterparts. The median length of hospital stay is needs to be converted to a standard open Whipple. 6.2 days (range, 5.2-18.8), which compares favorably to The patient requires an upfront frank preoperative open Whipple procedure,where the median length of discussion regarding the novel approach of the minimally 15 hospital stay is 7.9 days.10 One of the principal objections invasive pancreaticoduodenectomy. Informed consent can to the robotic procedure is the increased duration of be obtained if the benefits, risks and the alternatives—an operating time. The mean robotic operating time is 8 hours open procedure—are discussed in detail. The robotic team (range 5.9-9.6), which again compares favorably open should consist of expert pancreas and skilled robotic surgery where the mean operating time is 5.4 hours.10 surgeons, nurses and operating room technicians. When the The robotic Whipple needs to conform to the standards surgical team is motivated to push the frontiers of pancreas that have been set and validated for an open Whipple. surgery, the patient will benefit from the minimally invasive Modifications and/or shortcuts to allow for use of the robot procedure. should be avoided if the robotic resection cannot be REFERENCES performed to a similar standard to the open procedure, then the procedure needs to be converted. 1. Kakar PN, Das J, Roy PM, Pant V. Robotic invasion of operation theatre and associated anaesthetic issues: A review. Indian Giulianotti et al have reported a series of eight patients J Anaesth 2011;55:18-25. in whom pancreaticoduodenectomies were performed 2. Weisbin CR, Montemerlo MD. NASA’s Telerobotic research completely laparoscopically with the assistance of the program. Appl Intell 1992;2:113-25. robot. In this advanced technique, the hepaticojejunostomies 3. Kwoh YS, Hou J, Jonckheere EA, Hayall S. A robot with improved absolute positioning accuracy for CT guided and gastrojejunostomies were handsewn intracorporeally stereotactic brain surgery. IEEE Trans Biomed Engng Feb and the remnant pancreatic duct was injected with surgical 1988;35(2):153-61. glue.28 4. FDA. Computer-assisted surgery. An update. 44 JAYPEE WJOLS

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